Provider Demographics
NPI:1760566772
Name:SPENCER, MARY J (DC)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:J
Last Name:SPENCER
Suffix:
Gender:F
Credentials:DC
Other - Prefix:DR
Other - First Name:MARY
Other - Middle Name:J
Other - Last Name:DIFEDE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:503 W 10TH ST NE
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165-2607
Mailing Address - Country:US
Mailing Address - Phone:706-234-3031
Mailing Address - Fax:706-234-2046
Practice Address - Street 1:503 W 10TH ST NE
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-2607
Practice Address - Country:US
Practice Address - Phone:706-234-3031
Practice Address - Fax:706-234-2046
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR004814111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA55001308AMedicaid
GA35ZCCJHMedicare ID - Type Unspecified
GA55001308AMedicaid